Youth Form

  • Date(*)
  • Your Name(*)
  • Your Address(*)
  • City(*)
  • State
  • Zip Code(*)
  • Phone Number(*)
  • Birth Date(*)
  • SS#(*)
  • Mother's Name
  • Legal Custody of Youth?
     Yes No

  • Mother's Address
  • City
  • State
  • Zip Code
  • Mother's Occupation
  • Mother's Employer
  • Mother's Home Phone
  • Mother's Work Phone
  • Father's Name
  • Legal Custody of Youth?
     Yes No

  • Father's Address
  • City
  • State
  • Zip Code
  • Father's Occupation
  • Father's Employer
  • Father's Home Phone
  • Father's Work Phone
  • Legal Guardian
  • Guardian's Address
  • City
  • State
  • Zip Code
  • Home Phone
  • Work Phone
  • Relationship to Youth
  • Youth's School
  • Teacher
  • Grade
  • Special Classes
  • Please complete the following medical information:

    Do youth take regular medications?
     Yes No

  • If so, what?
  • Family Physician
  • Date of Last Visit
  • Does Youth Smoke?
     Yes No

  • If so how much?
  • Previous Mental Health Services:

  • Type of Services
  • Provider
  • Dates of Services
  • Current or expected legal involvement?
     Yes No

  • If yes, explain
  • Referred by
  • Relationship
  • Emergency Contact(*)
  • Address
  • City
  • State
  • Zip Code
  • Phone Number
  • Financially responsible party:
     Self Other

    Please provide the following information about the Financially Responsible Person, If it is not the patient:

  • Name
  • Age
  • SS#
  • Relationship
  • Home Phone
  • Work Phone
  • Employer
  • Occupation
  • Billing Address
  • City
  • State
  • Zip Code
  • Your Email(*)
  • captcha

  • Enter the Above Text(*)

Fees and Payments:

My fee is $200.00 for individual and $200.00 for family/couples per a 50-minute appointment. Special fee structures for certain specified tasks such as psychological testing; consulting, or court-ordered appearances will be discussed with you and agreed upon before any actions are taken. While Tennessee law permits minors sixteen years and older to consent to mental health care without parental consent, I hope and expect that minors will obtain permission from their parents and their parents will be responsible for payment.


My secretary typically schedules my appointments for my patients but sometimes she is not available and I will schedule the appointments for myself.

Since patients are seen by appointment only (unless an emergency situation dictates otherwise), the appointment time given is reserved for you. Please give at least forty-eight (48) hours notice if you must cancel your reserved time. In the absence of such circumstances, you will be charged your usual fee for appointments not cancelled twenty-four hours prior to the time. Please understand that insurance companies cannot be charged for missed appointments and you are fully responsible for any charge due to a missed appointment.

Emergencies and Telephone Calls:

While you will be seen at a reserved time, which fits your schedule demands and my availability, there may arise occasions where you need to talk to me between appointments. Should you need to talk to me between appointments and you call during normal office hours, I will return your call as promptly as I can. However, I am often unavailable for emergencies. If you are in a crisis and you require an immediate response or a response before I can get back to you, call 911 or call the Crisis Center at 244-7444 or go to the nearest emergency room. I do not carry a pager and my practice is not organized to work with patients who often expect to be in crisis.

Insurance Usage and Issues of Confidentiality and Privileged Communications:

Many patients elect to file third party insurance coverage for services rendered. We will file insurance for you, provided you authorize us to do so and provide us with the necessary information for filing such claims. However, we do require payment for services up front. We will gladly reimburse you for any insurance payments.

If you are a Medicare patient or are Medicare eligible and consulting Dr. David McMillan, you need to know that Medicare will likely not pay for his services. Dr. McMillan will not bill Medicare because he does not consider his services to you to be medically necessary. He will not give you a medical diagnosis and he will not treat you for a medical disorder.

This means that you are completely responsible for the payment of Dr. McMillan’s fee and that he will not submit any documentation of your consultations with Dr. McMillan to Medicare or any third party insurance program. By signing this form below you have indicated that you have been informed of the above.

As you know, the world of health care has experienced a tremendous change in the manner in which insurance companies reimburse for third party payment. Many plans require an initial pre-certification of care before you can use your insurance benefits. It is your responsibility to make sure such pre-certification requirements are met by you if you elect to use your insurance benefits (i.e., referral from your primary care medical doctor, employee assistance program, other “gatekeeping” mechanisms such as calling an 800 number for approval).

Your Informed Consent to Care:

I authorize the release of any medical or other information necessary to process claims from this office. Also, I have provided this information to you in the hope of fully informing you about the policies of my office and some of the parameters of care you will receive here, such as the importance of confidentiality. Psychiatric and psychological care, like other things in life, offer no absolute guarantee of success and there are limitations to any form of care offered a patient. Since such limitations are always a function of the particular problem in question, I invite you to discuss your treatment plan with me. After we have met to discuss your concerns, I will construct an individualized treatment plan and share it with you so that you and I have our plan for what problems we are going to solve and how.

Please feel free to discuss any of these matters with me in more detail. By signing below, you acknowledge having read, understood, and agreeing to these policies and procedures. Your signature acknowledges your informed consent for care.

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115 28th Avenue North Nashville, TN 37203 | 615 327-2183
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